Credit Card Authorization

I

Authorize AITU to charge my credit card

Account indicated below for a total of

Made in

First Payment Date *

Amount Spent by $

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Second Payment Date

Second Amount Spent by $

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Third Payment Date

Third Amount Spent by $

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Forth Payment Date

Forth Amount Spent by $

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Fifth Payment Date

Fifth Amount Spent by $

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Sixth Payment Date

Sixth Amount Spent by $

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Seventh Payment Date

Seventh Amount Spent by $

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Eighth Payment Date

Eighth Amount Spent by $

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Ninth Payment Date

Ninth Amount Spent by $

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Tenth Payment Date

Tenth Amount Spent by $

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Eleventh Payment Date

Eleventh Amount Spent by $

Name *

Address *

Phone# *

City*

State *

Zip *

E-mail *

Confirm E-Mail *

Name *

Address *

Phone# *

City*

State *

Zip *

E-mail *

Confirm E-Mail *

Account Type

VisaMasterCardAMEXDiscover

Cardholder Name

Account Number

Expiration Date

CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX )

SIGNATURE

Date